BOOK REVIEWS - The National Medical Journal of Indiaarchive.nmji.in/approval/archive/Volume-6/issue-4/book-reviews.pdf · Book Reviews THENATIONAL MEDICAL ... related studies either

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A growing number of physicians around the country havebecome more open to alternative approaches, attuned to theway that the mind, body and life-style interact. There seemsto be no equivalent in medical practice to the phenomenonof 'energy'-the common denominator in alternative healing.'Unseen, immeasurable energy has been observed throughmany centuries by many cultures', states an Americanacupuncturist, 'in India they call itprana, in Russia, bioplasm.'The ubiquitous 'mind over body' movement is now gainingrapidly over resistance by the medical establishment; mind-body medicine will be in widespread practice in the future,because of patient demand. In one poll, among those whohad not sought help from a practitioner of alternativemedicine, 62% said they would consider such help. Eighty-four per cent of those who had been so treated stated thatthey would return for treatment; 10% said they wouldnot. As the country begins to accept, indeed demand, healthcare reform, alternative medicine is emerging high on thelist deemed by the public to be important. Even the USGovernment is starting to think this way. A new Office ofAlternative Medicine at the National Institutes of Health isseeking proposals from researchers outside the medicalmainstrearn.?The establishment defines unconventional therapies as

those interventions not taught widely at US medical schoolsor generally available at US hospitals. A national survey ofsixteen such therapies revealed some interesting facts. Anestimated one in three persons used unconventional therapyin 1990. The number of visits was greater than the numberof visits to all primary care medical doctors. One in fourAmericans who see their medical practitioner for a serioushealth problem is likely to be using unconventional therapyat the same time; more interestingly, 7 out of 10 such patients

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THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 6, NO.4, 1993

do not tell their physicians that they use unconventionaltherapy. All socio-demographic groups are involved.Unconventional therapies are usually employed in con-

junction with rather than as replacements for establishedmethods; further, the majority of usage is for conditions thatare not life-threatening. One-third of the respondents in thisstudy indicated that their use of unconventional therapy wasnot for the primary condition. Overall, it appears that a sub-stantial amount of these therapies are used for minor medicaldisorders, health promotion and for disease prevention.'Given the climate of strained relationships with their

patients, doctors would now be well advised to learn moreabout the scope of unconventional therapy. Patients do nottell them that they use such therapy for fear of criticism andalso perhaps because doctors are unable to discuss theseareas as they do not know or care to know enough aboutthem. Although some physicians might be uncomfortablewith this line of history-taking, this study as well as all themedia attention in these areas clearly shows that improvedcommunication can enhance the doctor-patient relationshipleading to better clinical care, and avoid the potential harmresulting from some methods of unconventional therapy. 4

REFERENCES1 Wallis C. Why new age medicine is catching on. Time 1991Nov 4:68.2 Moyers B. How the mind can heal the body. USA Weekend 1993 Feb 5:4.3 Eisenberg OM, Kessler RC, Foster C, et al. Unconventional medicine in theUnited States. Prevalence, costs and patterns of use. N Engl J Med 1993;328:246-52.

4 Kronenfeld 11, Wasner C. The use of unorthodox therapies and marginalpractitioners. Soc SciMed 1982;16:1119-25.

YVAN 1. OAS OORES SILVA

Imperialism and Medicine in Bengal-A Socio-historicalPerspective. Poonam Bala. Sage Publications, New Delhi,1991. 174pp, Rs 185.

This book is a result of the research carried out by PoonamBala for her PhD degree from the University of Edinburgh.The India Office Library in London; the Edinburgh UniversityLibrary; the National Library, the Asiatic Soeiety Libraryand the Bengal Secretariat Library in Calcutta; the NationalArchives of India in New Delhi and various other institutesprovided material for her study. As anyone who has venturedinto this field knows, such information is not easily collected,the researcher having to delve into files, reports, despatchesand volumes that may, at first sight, appear to have no con-nection with the subject. Dr Bala has also referred to recordsdestroyed by fire or labelled too fragile to handle.She refers to and appears to sympathize with the oft-voiced

complaint that indigenous forms of medicine were suppressedby invaders-initially from the northwest and later fromEurope. She quotes R. C. Majumdar's statement (1971) tosuggest that the British, keen on foisting their brand of. medical practice, hastened the decay of Ayurvedic andUnani medicine. The first chapter, 'Indigenous medicine inancient and medieval India', traces the evolution of theprofession from the Vedic period to the Mughal era andconcludes that the indigenous systems of medicine suffereda severe setback following the withdrawal of support by thestate and the middle classes.Having confined herself to Bengal (which then included

what is now Bangladesh), she has been deprived of the studyby Charles Morehead in Bombay in the 1830s (at the behestof the then Governor, Sir Robert Grant) which showedclearly that the Indian forms of medicine were in decline longbefore the British came. It was not just the prohibition of

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contact with the dead that brought about this degeneration,though this played a role by facilitating the transfer of the artand science of medicine from the intelligentsia to the illiterateand unthinking. Blind adherence to the teachings of ancientauthorities, regression of the science of medicine intoritualistic practice and a total absence of questioning andinnovation were other factors. While in the West physiciansand surgeons were blazing new trails, India had barber-surgeons almost up to the mid-1850s.The indigenous medical policy (of the British) in Bengal

may be summed up in three phases, says Bala: 'peacefulco-existence up to the 1860s followed by tension between theBritish and Indian systems from the increasing professionali-zation of medicine ... and standardization of drugs in Britainand finally, the rise of the chemical industry in Europe andincreasing professionalization of medical practice whichposed a far greater threat to indigenous medicine' (p. 40).Bala explains, in Chapter 3, that by professionalization sherefers to the exhibition of 'professional attributes such asautonomy in terms of working conditions'.As proof, she traces the development of the Native

Medical Institution (NMI) in Calcutta where instruction wasinitially through the vernacular but 'ended in the triumph ofthe Anglicists in introducing the English language andEuropean sciences in India' (p. 41). 'The halcyon days of theNMI virtually came to an end in 1835 ... [after] the NMI wascaught up in the reformation tactics of William Bentinck'(pp.41-2).Bala suggests that this abandonment of the synthesis of

Indian and western forms of medicine justified the protestsby Indian nationalists in later years. The histories of themedical colleges in Calcutta, Madras and Bombay suggest adifferent viewpoint. The experiment of medical education innative languages failed in Bombay as well. Morehead'analysed this in considerable detail. He found natives notproficient in English unable to cope with modern scientificprinciples. He and Sir Robert Grant questioned the conceptof setting up medical schools to create half-baked doctorssolely in order to relieve British medical personnel of the taskof looking after 'native soldiers'. Instead, they proposed thecreation of a medical college at par with the best in Britain toproduce full-fledged doctors. The foundation of the medicalcollege in Bombay, later named after Sir Robert Grant, wasbased on this scientific and objective analysis. However,Bala's review of this vital segment of her story is sketchy.She describes drugs native to the Indian soil and how they

were incorporated into the British pharmacopoeia. She attri-butes the use of British drugs in preference to Ayurvedic andUnani remedies to the rise of the drug industry in the West.One senses her disapproval of the dismissal of the humoraltheory of disease (and other similar concepts) and practicesbased on them by British and Indian doctors (and, indeed,by Mahatma Gandhi in 1921). She favours further researchin indigenous medical science and its improvement in thelight of western medicine (p. 53).Chapter 3 deals with the development of the Calcutta

Medical College, dissections by 'native students', travel toEngland by four of the first batch of -graduates from thecollege for further study and growth of the institution till 1860and the rise of a class of Indians well versed in English. Thestate encouraged the development of two streams of Bengalidoctors-one for 'inferior-grade employment' in the rural

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areas and the other for their compatriots in the cities. Theformer were progressively phased out whilst the latter wereupgraded by improving standards in the medical college. Thefamed kavirajas were gradually supplanted by those holdingmedical degrees. Once registration of medical practitionersbecame compulsory, indigenous doctors were placed at adistinct disadvantage. Attempts by nationalists to reviveAyurveda and Unani met with little success as the peopleturned, in preference, to graduates from the medical college.'Integration' of the more popular practices in modernmedicine into Ayurveda dealt the final blow.Chapter 4 deals with public health in Bengal. The import

of western concepts of infection, germs, immunity and vacci-nation enlarged the scope of activity of the medical professionfrom curative measures to prevention of disease not only inthe immediate environs of the doctor but in places furtherafield as well. The author briefly describes Indian attitudestowards disease, especially those of the contagious variety.We learn that until the second half of the nineteenth century,there was no deity associated with cholera. Native faith inreligious cures for epidemics collided with practices such asquarantine imposed by the British. Bala suggests that someBritish practices actually worsened the health of the popula-tion. 'Expanded water supplies in India ... led to breedingof mosquitoes and ... intensificaton of malaria' (p. 106)and concludes that public health policies in Britain wereinappropriately transferred to India.Chapter 5 discusses ethnic aspects of medical education in

Bengal. The bhadralok ('the respectable people', those richenough to afford an appropriate education) dominated.Table 2 on p. 117 analyses how well-paid posts in the

Government of Bengal were filled up between 1867 and1871. Whilst the Muslim population in Bengal then wasroughly half that of the Hindus, the posts allotted to themwere 25% or less than the posts allotted to Hindus.The appendices provide information on medical literature

and practice in ancient India and during the Mughal period.Their value is diminished by the absence of references in thissection. Table A-16 summarizes stages in the development ofthe Calcutta Medical College.Some references jar. Is there no better evidence for

'the British victory at the Battle of Plassey in 1757' thanDr A. R. Desai's Social background of Indian nationalism(p. 15)? At times the reader has to struggle to get at whatthe author is trying to say. Take the following sentence: 'therise of the chemical and drug industry ... created a vast gulfthat ... could not be breached' (p. 64). Is bridged the wordshe wanted?She ends her preface to the book with the statement: 'If I

can elicit sufficient interest amongst the readers-medicalhistorians, sociologists and other scholars-to undertakerelated studies either on colonial or in contemporary Indiathen the book will have served its purpose.' Whilst the bookmay fulfil her hope, the reader would have benefited if shehad provided a much more detailed and fully documentednarrative. As it stands, she leaves the reader pondering overher views without gaining much in terms of hard facts.

SUNIL K. PANDYADepartment of Neurosurgery

KEM HospitalBombay

Maharashtra

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Neurological Anatomy. Ourashi M. Ali. Macmillan, NewDelhi, 1993. 308pp, Rs 125.

This book seeks to present the facts on neuroanatomythat conform to the needs of undergraduate medical students.Both the central and peripheral nervous systems areincluded. The coverage of the central nervous system may beregarded as adequate for students looking only for bareessentials of the subject. The treatment of the peripheralnerves is sketchy and most teachers of anatomy would find itinadequate.The text is well written, the language used is clear and

correct. I did not notice any typographical errors. The com-posing, printing and paper used are above average (for anIndian textbook). The line drawings are neat but becauseof considerable variation in the degree of reduction, thelabelling is far too bold in some figures (e.g. Fig. 17.14)and too small in others (e.g. Fig. 1.5). Many labels on thefigures are not parallel to one another or to the text, andthis is a bit jarring (e.g. Fig. 1.5). The half-tones are reason-ably well printed but bold labels pasted over them (again atvarious angles) make many of them unattractive. In thephotographs of transverse sections through the brains tern thepointers often merge with the background rendering themuseless (e.g. Fig. 7.2). These defects mar the appearance of abook which is otherwise well produced.Although the price is not unreasonable, keeping in mind

present-day publication costs, I fear it is likely to be a dis-incentive to prospective buyers.

INDERBIR SINGHDepartment of Anatomy

Medical CollegeRohtak

Haryana

Clinical Neurology. U. N. Panda and Laxmi Chand. Inter-print, New Delhi, 1993. 324pp, Rs 95.

The book is introduced as a quick reference in neurology forundergraduate as well as postgraduate students in medicine.It provides a great deal of information in a concise mannerand the authors and publishers should be congratulated onits price. Where the book falls short, however, is in informingus about common conditions likely to be seen in our country.Thus several new diseases are reviewed very briefly, or notmentioned at all. There is no discussion on Japanese Bencephalitis, Kyasanur forest disease, neurotoxic snake bite,hereditary ataxia with slow eye movements, south Indianparaplegia or tropical spastic paraplegia, organophosphorouspoisoning or lathyrism.Cerebral malaria gets just half a page. I could find only six

lines on leprosy (and it is not included in the index at all).Neurocysticercosis is discussed without describing a singlering or disc-enhancing lesion (or disappearing lesion) whichis a uniquely Indian problem and seen in 25% of all patientswith focal epilepsy. The use of albendazole in the treatmentof neurocysticercosis is not mentioned.The organization of the chapters leaves much to be desired.

The chapter on cord diseases starts for some reason withvascular diseases which are quite rare. It describes traumatic

THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 6, NO.4, 1993

lesions and compressive lesions followed by a description ofacute transverse myelitis. It then returns to chronic lesionssuch as subacute combined degeneration and motor neuronedisease. Four pages after cord compression is a descriptionof intramedullary metastases and six pages later the authorscome back to describe spinal tumours. I am sure the studentwould be better served if the discussion was in the followingorder: chronic spastic paraplegia, acute upper motorneurone paraplegia, lower motor neurone lesions such aslumbar disc disorders and sciatica. And I am not sure whatplace fibrositis or fibromyalgia has in a chapter on corddisease.Another unfortunate example is the chapter on demyeli-

nating and degenerative diseases. Here .progressivesupranuclear palsy is described on two separate occasionsfive pages apart. The differences between tardive dyskinesiaand Huntington's chorea appear in the text on pages 202 and203 but the table is not seen till page 214. A table differentiat-ing depression and pseudodementia appears for the secondtime and the chapter ends with opium and barbiturates. Thetext does not discuss demyelination or cerebral degenerationas a result of these agents.There are a number of major omissions and several factual

errors. Among the first is the omission of electrocardio-graphic changes in Duchenne's muscular dystrophy, the factthat Becker dystrophy is also due to an abnormality in thedystrophin gene and is allelic to Duchenne's, the nature ofthe prion proteins and their importance in spongiformencephalopathy, the causes and surgical treatment oftrigeminal neuralgia, and the anterior operative approach tocervical spondylosis. The meningovascular forms of neuro-syphilis affecting the cord are mentioned in one line.Among the factual errors, I can mention that cerebellar

nystagmus does not have its fast component to the side ofthe lesion, constructional apraxia is not seen only in non-dominant parietal lesions, and of course Guillain-Barresyndrome is not a post-infectious myelopathy. The myoclonusof subacute sclerosing panencephalitis and Creutzfeldt-Jacob disease is not a myoclonic epilepsy; the lateralmedullary syndrome does not have posterior column sensoryloss on the opposite side (pain and temperature is lost) andthe VDRL test is not always positive in the cerebrospinalfluid in meningovascular syphilis. This list of omissions anderrors is by no means complete.The idea of producing a low cost book on clinical neurology

for Indian students seems eminently worthwhile but greaterstress on Indian diseases and attention to editing would haveresulted in a much more useful publication.

R. s. WADIAB. J. Medical College

Sassoon HospitalPune

Maharashtra

Health Research Methodology. A Guide for Training inResearch Methods. World Health Organization. OxfordUniversity Press, New Delhi, 1993. 250pp, Rs 200.

This book provides a fair amount of information required forepidemiological investigations, both in planning and

CORRESPONDENCE

analysis. The introduction states that this is an edited versionof the training modules that have been used for a number ofshort courses on this topic sponsored by the World HealthOrganization's Regional Office for the Western Pacific andthat the manual might be useful to students who are writingtheses to meet academic requirements in health-relatedsubjects.The topics in the book have been covered under 11chapters.

After an introduction to research planning in the first five,the manual discusses 'bias, confounding and basic riskmeasurements' in Chapters 6 and 7. Chapters 8 and 9 dealwith actual data analysis covering tests of significance andassociation as well as causation. The ethical aspects ofhealth research have been covered in Chapter 10. The detailsof preparing a typical research proposal have been lucidlydealt with in Chapter 11.At the end of the book three annexures are given, the first

two explain the design of a health research questionnaire andconstruction of statistical tables and graphs. In Annexure 3,details of a workshop on 'Health Research Methodology'have been explained with the help of flow charts.This practical training manual covers, with the help of

several examples, the basic concepts and principles ofscientific research, from the selection of the area of researchto the analysis of data and interpretation of results.The topics have been covered systematically, explaining

various essentials of conducting a health research study and

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. the methods of analysis of data. The best parts of the bookare the two chapters on bias and confounding and basic riskmeasurements. These topics have been covered in simplelanguage with clear examples. Extensive empirical data havebeen presented in the chapter on the tests of significance.Similarly •..the chapter on association and causation will alsobe very useful to readers. However, the chapter on samplesize determination and sampling methods should have beenillustrated with more examples. Though different samplingmethods have been explained in this chapter the reader mayhave to supple merit his knowledge by reading other books aswell.The ethical aspects of health research (covered in only four

pages) provide useful information but the researcher mayhave to refer to a book dealing more specifically with thistopic if he or she needs help on this important problem. Thethree references given at the end of this chapter suggestwhere this help might be found.Though several books are available on health research

methodology, I feel that this book is among the best and willbe very useful to both statisticians and health care personnelengaged in research.

K. R. SUNDARAMDepartment of Biostatistics

All India Institute of Medical SciencesNew Delhi

The Consumer Protection Act and I

Sir-I have recently had an unfortunate experi-ence as a result of the Consumer ProtectionAct. A 37-year-old lady was admitted to anursing horne in Delhi on 6 May 1991 wantingher fallopian tubes to be reopened so that shecould conceive again. Both her sons had died,she had only one living daughter and hadundergone a tubectomy during a Caesareansection 12years previously.A hysterosalpingogram (HSG) showed that

the uterine cavity was well seen but no tube wasvisible on the right side and a small part of thetube was seen on the left. We explained to thepatient that a tuboplasty could be done but ather age the chances of conception were small.. We also said that since we used microsurgicaltechniques the results of the reversal oftubectomy were generally better in our handsthan in others and cited examples of childrenhaving been born to other patients who hadundergone a similar procedure.Our patient underwent a tuboplasty on 8 May

1991 and immediately after the operation injec-tion of methylene blue into the uterus showed agood flow of the dye through both tubes. Theovarian capsules appeared thickened, so we

performed a wedge resection of the ovaries tohelp ovulation.She was discharged well on 15 May 1991.

Three months after the operation another HSGshowed that the anastomotic site allowed a freeflow of contrast up to the fimbriae but notbeyond. We explained to the patient that thismay be because of fimbrial adhesions as well assome tubal spasm because the examination hadbeen done only three months after surgery. Wedid not see the patient afterwards but were toldthat she had undergone two more HSGs else-where both of which had showed that the rightfallopian tube was open while the left showedscanty spillage of contrast into the peritoneum.However, eight months later, to our surprise,

we heard that this same patient had filed a suitagainst us under the Consumer Protection Actstating that she had undergone this operationbecause she wanted a son and she had been tonursing homes where the sums demandedranged from Rs 5000 to Rs 8000. However, theywere prepared to give only a 25% to 50%guarantee of success but our nursing horne, shealleged, had given a 100% guarantee andalthough we had asked for Rs 12000 she hadopted to have the procedure done by us. Thiswas completely untrue.

After hearing about this charge, we sent oneof our doctors to the patient's house and toldher that the operation had indeed achieved itsimmediate aim but it was too early to expectpregnancy. We also told her that she shouldhave corne back to us instead of going to courtif she felt that she had been wronged.She refused to acceptour explanation. So we

decided to contest the case because we weresure we could vindicate ourselves against thetwo main charges: (i) that we gave a 100%guarantee and (ii) that the operation had beenunsuccessful.At the first hearing, we provided a written

statement denying all the allegations. Our con-tention was that even if one tube was found tobe open in one of three consecutive Xvraystudies, it meant that the operation had beensuccessful. We quoted extensively from TeLinde's operative gynaecology' to supportour claim.We were told by the court to submit this in

the form of an affidavit which we did at the nexthearing.The patient then filed a counter-affidavit

repeating all she had said and insisting, withoutany proof whatsoever, that a 100% guaranteehad been given.